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* 1. Name and Credentials (ex: John Jane Smith, MD)

PREAMBLE

ASCCP members and the general public place great trust in the work of the Society. Real or perceived undisclosed relevant financial relationships may jeopardize that trust and ASCCP’s effectiveness. Relevant financial relationships also may affect the objectivity of decisions that ASCCP officers and volunteers make. To minimize the potential impact of possible relevant financial relationships, the Board of Directors has determined that all participants in ASCCP activities must report all real or potential relationships prior to the activity being developed and delivered to the learners.

Additionally, the ACCME Standards for Integrity and Independence in Accredited Continuing Education require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education.

Please disclose all financial relationships that you have had in the past 24 months with ineligible companies (see definition below). For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.

An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards.

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* 2. I have read and understand the Preamble.

DISCLOSURE

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* 3. I am participating in an ASCCP activity as the following:

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* 4. I hereby disclose the following relationships (financial) as the only relationship that I have had over the past 24 months:

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* 5. If you answered that a relationship (financial) does exist, please complete:

  Company/Institute Role Has this relationship ended? If yes, please select a month and year this relationship ended.
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DUTY TO RESPECT CONFIDENTIALITY

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* 6. I will not, without appropriate authorization, disclose to any third party any confidential information or document to which I obtain access by virtue of my service to the Society. This includes, but is not limited to, discussions or documents relating to strategies or plans, documents marked 'confidential', financial or marketing information, or unpublished data. If I have any reasonable doubt about whether particular information or a particular document is confidential, I will not make disclosure unless I have first clarified the situation with appropriate Society officials or staff and obtained authorization.

ATTESTATION

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* 7. I understand that if any subject is discussed or presented to me for action that creates a conflict between any personal or other extra-Society interests and my Society responsibilities, I will not participate in the subject in any capacity, unless officially requested to do so. I understand that all materials I develop shall be free of commercial bias and shall reflect best available evidence. I agree that no part of any presentation I may make in public contains individual identifying information or if Individual identifying information is included, I have obtained written consent for presentation. I understand that this information will be held confidential by the Society, except that it may be released to the Board of Directors and the Ethics Committee of the Society. Information also may be released when participants participate in continuing medical education activities when required to conform to the guidelines of the ACCME. This information may be used by the Society to determine when relevant financial relationships appear sufficient to preclude participation in decision-making/participation in an accredited educational activity.

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* 8. I hereby disclose the following membership and roles associated with the other scientific societies:

SOCIETIES

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* 9. If you answered that a relationship does exist, please complete:

  Society/Name Role
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